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NYS Health Profiles
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Scope: Isolated
Severity: Actual harm has occurred
Citation date: October 21, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Actual harm has occurred
Citation date: October 21, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2022
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Post Survey Revisit (PSR) conducted on 10/21/2022, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for [MEDICAL CONDITION] care. Specifically, during observation of [MEDICAL CONDITION] care for Resident #1, who was on Contact and Droplet precautions due to Carbapenem-resistant [MEDICATION NAME] (CRE) in sputum and Extended Spectrum Beta-Lactamase (ESBL) infection in the urine, Respiratory Therapist (RT) # 1 did not utilize appropriate Personal Protective Equipment (PPE); did not follow infection control protocols while changing the [MEDICAL CONDITION] inner cannula; and did not wash their (RT #1) hands during the procedure. The finding is: The [MEDICAL CONDITION] Care and Documentation Policy dated 8/96 and last revised on 9/2022 documented procedures that included but were not limited to: wash hands, don (put on) gloves and any other PPE that may be appropriate, mask and goggles if risk of splashing. Remove disposable inner cannula and discard. Insert sterile disposable inner cannula make sure it snaps into place. The Handwashing/Hand Hygiene Technique Policy dated (MONTH) 2013 documented handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections. The indications for antiseptic Handwashing included but were not limited to when providing resident care which involved bloody or body fluids, bodily excretion, and secretions. The Transmission Based Precaution Policy dated 7/15/2022 documented for residents on Contact Precautions the healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. For residents on Droplet Precautions if there is a risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn. The Personal Protective Equipment Policy dated 8/2021 documented to perform hand hygiene before donning gloves and after glove removal. The policy further documented that glove are not substitute for hand hygiene. The policy included gowns are to be worn to protect arms, exposed body areas and clothing from contamination with blood, body fluids, and other potentially infectious material. Indication/consideration for PPE use of gloves included but were not limited to: perform hand hygiene before donning gloves and after removal; gloves are not a substitute for hand hygiene; and change gloves and preform hand hygiene between clean and dirty tasks. Resident #1 was readmitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. The MDS documented that the resident was ventilator dependent, required oxygen therapy, suctioning and [MEDICAL CONDITION] care. The physician's orders [REDACTED]. Change disposable [MEDICAL CONDITION] inner cannula every shift and as needed for hygiene. The Comprehensive Care Plan (CCP) for Multi Drug Resistant Organisms (MDRO) colonization, Pseudomonas aeruginosa, (Carbapenem Resistant) CRE in the sputum, and ESBL in the urine dated 8/31/2021 and last revised on 7/29/2022 documented Resident #1 was on standard and contact precautions effective 8/31/ 2021. Resident #1's care equipment be appropriately cleaned, disinfected, or sterilized according to facility protocol. The CCP for [MEDICAL CONDITION] for Impaired breathing mechanics, [MEDICAL CONDITION], vent dependence dated 5/06/2022 documented to provide [MEDICAL CONDITION] care daily and as needed. Resident #1, who was ventilator dependent, was observed for [MEDICAL CONDITION] care on 10/21/2022 at 10:40 AM. There was signage outside the resident's room with instructions Stop see the nurse for appropriate PPE use. RT #1 was wearing a face mask and eye protection; however, was not wearing a gown. RT #1 was observed donning a pair of disposable gloves without washing their hands before donning the gloves. RT #1 pulled Resident #1's privacy curtain around the resident's bed to provide privacy. RT #1 removed water cups, napkins, and pieces of gauze from the over-the-bed table then proceeded to clean Resident's #1 chest area. RT #1 set up the sterile field on the over-the-bed table to replace the resident's [MEDICAL CONDITION] inner cannula wearing the same gloves. RT #1 then opened a sterile glove packet while wearing the same disposable gloves. While wearing the same disposable gloves RT #1 was observed inserting their right-hand pointer, middle and ring fingers into the sterile glove as a second layer. RT #1 did not remove their soiled gloves and did not wash their hands before they opened and utilized the sterile glove. RT #1 was observed removing the [MEDICAL CONDITION] inner cannula with the right hand three fingers and then replaced the sterile inner cannula with their right hand while stabilizing the surrounding area with the left hand. RT #1 was interviewed on 10/21/2022 at 10:50 AM and stated that they do not remove their soiled gloves before they apply sterile gloves for any procedure. RT #1 stated they will not remove their used gloves and wash their hands before they open a sterile glove packet to apply the sterile gloves, since this was their routine practice. RT #1 stated there was no reason to remove the soiled gloves and wash their hands and that touching surfaces will not make the gloves soiled. RT #1 stated they did not use a disposable gown because Resident #1 did not have any infection control concerns. RT #1 stated they did not notice the stop see the nurse for appropriate PPE use sign that was posted outside the resident's room. RT #1 stated they were educated on the importance of washing their hands and using the correct technique to apply the sterile gloves; however, could not recall when they received the training. RT#1 stated that if we do not use the appropriate glove technique, the resident can get an infection because of germs on the gloves. RT #2 was interviewed on 10/21/2022 at 11:10 AM and stated that they overheard RT #1's sterile glove usage technique while they (RT#2) were outside Resident #1's room. RT #2 stated RT #1 was supposed to remove their soiled gloves and wash their hands before they applied the sterile gloves to change Resident #1's inner cannula. The Director of Respiratory Therapy was interviewed on 10/21/2022 on 2:00 PM and stated that RT #1 should have taken their soiled gloves off and washed their hands before applying the sterile gloves to complete the inner cannula change task. The Director of Respiratory Therapy stated that RT #1 put Resident #1 at risk of contracting bacteria, since RT #1 had not used proper technique for changing the inner cannula. The Infection Control Nurse, who is also the Director of Nursing Services (DNS), was interviewed on 10/21/2022 at 2:30 PM and stated that they educated RT #1 upon hire and periodically regarding hand washing and proper use of gloves. The DNS stated RT #1 failed to remove their soiled gloves prior to wearing sterile gloves. The DNS stated Resident#1 had an infection in the sputum and RT #1 put the resident at risk for further infection. RT#1's sterile glove technique was not acceptable. The DNS further stated that RT#1 should have worn a disposable gown while providing care to Resident #1 since the resident was on contact and droplet precautions. 415. 19 (a)(1-3); 415. 19(b)(4) | Plan of Correction: ApprovedNovember 9, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Actions 1. The Respiratory Therapist involved in the care of this Resident who breeched Infection Control Practice was disciplined by the Director of Respiratory Therapy regarding the breech of Infection Control and failure to follow Policies as educated. 2. It was noted that this Employee had been recently educated and observed for competency on 10/17/22 and despite same violated Facility Policies, therefore the involved RT was terminated from the Facility on 10/21/2022 3. The Director of Respiratory Therapy will meet with all Respiratory Therapists on all shifts to review the deficient practice as recently cited with the staff; as well as to do on site education regarding infection control policy including: hand washing, glove use, Transmission-Based Precautions [MEDICAL CONDITION] to ensure compliance. A copy of this onsite education and attendance will be filed for reference and validation. 4. Resident # 1 was seen and evaluated by the MD Pulmonologist on 10/25/22 and no new acute infection was identified. A progress note was documented in the EMR to validate this assessment. 5. Currently, Resident # 1remains on Transmission-Based precautions with all Infection Control measures implemented during care by all staff per policy and infection control requirements. II. Identification of Other Residents 1. The Director of Respiratory Therapy compiled a list of all residents on the Vent Unit who are on Transmission-Based Precautions as well as have [MEDICAL CONDITION] Care. 2. This list will be used by the RT Director and IP Nurse/Designee to make immediate full rounds on all shifts targeting the vent unit to ensure all infection control policies are being followed as per facility policy. An observational rounds tool will be developed to validate the full house rounds. Any quality issues identified /and or corrective actions implemented will be documented for validation. 3. Any staff member identified with a breech of Infection Control during these observation rounds will have immediate onsite education to ensure compliance. 4. Copies of the observational rounds tool and any onsite education will be filed in our P(NAME) book for validation and follow up for ongoing compliance. 5. The list will be used by the Director of Respiratory Therapy to provide direct observations of Infection Control Competencies on the following: Awareness by RTs regarding Residents who are on Transmission-Based Precautions Appropriate signage and availability of PPE Criteria for Residents on Transmission-Based Precautions are being followed Wearing appropriate PPE including Donning and Doffing gowns, eye shields, masks (N95 in addition if appropriate) and gloves Appropriate Hand Hygiene and glove use 6. Any RT staff identified with quality issues regarding Infection Control procedures will be re-educated by the RT and additional competency will be done to ensure sustainable compliance. 7. A copy of the competencies will be filed in our plan of correction book for reference and validation. 8. The DNS/Infection Preventionist Nurse (IP Nurse)/Designee identified and compiled a list all Residents on Transmission-Based Precautions. 9. This list was used by the DNS/Designee to make full house rounds on all shifts to ensure that staff were following all Infection Control Policies for Infection Control compliance including the following: Awareness by staff regarding Residents who are on Transmission-Based Precautions Appropriate signage and availability of PPE Criteria for plan of care for Residents on Transmission-Based Precautions are being followed Wearing appropriate PPE including Donning and Doffing gowns, eye shields, masks (N95 in addition if appropriate) and gloves Appropriate Hand Hygiene and glove use 10. Any staff member identified during observational rounds with quality issues regarding Infection Control procedures will be re-educated by the nurse auditor and additional ongoing audits will be done to ensure sustainable compliance . 11. A copy of the observational rounds will be filed in our plan of correction book for reference and validation. III. Systemic Changes 1. The Facility has contracted with a consultant to assist and develop a Directed Plan of Correction as per New York State DOH Directives. 2. The facility conducted a QA meeting on 11/1/2022 to discuss recent findings and to identify the root cause that resulted in the facility failure. Based upon identifying the root cause analysis, the facility developed systemic changes to implement corrective actions. 3. A copy of the root cause analysis will be filed for reference and validation. The analysis revealed despite education and recent competency the RT failed to follow the facility policy on infection control. 4. The Director of Respiratory Therapy in conjunction with the IP nurse reviewed the policies on Transmission-Based Precautions and [MEDICAL CONDITION] Care with a concentration on Infection Control compliance, and found same compliant. 5. All respiratory therapists will be re-educated on the Policy for Transmission-Based Precautions and [MEDICAL CONDITION] Care by the Director of RT and/or Staff Educator/Designee to ensure understanding of all components of infection Control. 6. The Lesson Plan will concentrate on the following: Following the plan of care for Infection Control including interventions for preventing transmission of infection Overview of directives and protocols for residents on Transmission- Based precautions Appropriate Hand Hygiene and glove use, including when to wash hands per policy and when to change gloves Donning and Doffing PPE prior to entering/exiting the room Appropriate use of Face Shield/Goggles and Masks (in addition to N95, if appropriate) Overview [MEDICAL CONDITION] procedures with a focus on Infection Control Directives 7. A copy of the education and attendance will be filed for reference and validation 8. As per ?ôIdentification of Other Residents?Ø; the Director of Respiratory Therapy/Designee will perform Competencies on all staff RTs to ensure compliant Infection Control practice in Transmission- Based precautions as educated as well as [MEDICAL CONDITION] . Any RT staff identified with quality issues regarding Infection Control procedures will be re-educated by the RT Director/Designee and additional competency will be done to ensure sustainable compliance and comprehension of policies as educated. A copy of the competencies will be filed in our plan of Correction Book for reference and validation. The DNS/IP Nurse has reviewed the Policy on Transmission-Based Precautions; the policies have been found compliant with Infection Control requirements. All Nursing and Care staff will be re-educated on the Policy by the Staff Educator/Designee to ensure compliance in Infection Control Policies. 9. The Lesson Plan will concentrate on the following: Following the plan of care for Infection Control including interventions for preventing transmission of infection Overview of directives and protocols for residents on Transmission- Based precautions Appropriate Hand Hygiene and glove use, including when to wash hands per policy and when to change gloves Donning and Doffing PPE prior to entering/exiting the room Appropriate use of Face Shield/Goggles and Masks (in addition to N95, if appropriate) 10. A copy of the Lesson Plan and attendance will be filed in the P(NAME) Book for reference and validation of this education. IV QA Monitoring 1. The Facility held a Special review QA meeting on 11/1/22 to discuss the recent findings from the Facility re- survey. The meeting was facilitated by consultant. The meeting focused on causative factors that contributed to the deficiency as well as triggers that may indicate deficient practice based on DOH findings and Facility ongoing newly developed Infection Control audits and competencies 2. The QA Committee also discussed the root cause of this deficient practice as well as QAPI improvement plans for sustainable compliance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2022
Corrected date: N/A
Citation Details Based on record review during the Life Safety Code Post Survey Revisit on 10/25/2022 the facility did not provide substantial information to demonstrate that the Plan Of Corrections were implemented for the identified improperly sealed floor slab penetrations by the HVAC and plumbing systems. The following was cited during the 08/22/2022 recertification survey: During the Life Safety Code inspections on 08/15/22, and on 08/16/22, between 8:30am and 3:00pm, and record review, it was noted that the facility had previously identified a total of approximately 946 separate improperly sealed plumbing and HVAC penetrations in floor and ceiling slabs. The plumbing penetrations come through the decking into a sheetrock wall above, and the HVAC piping come through the metal decking into the equipment above. During the Life Safety Code exit conference on 08/19/22 at 2:00pm, the Administrator and Director of Engineering were both made aware of the issues. 10 NYCRR 415. 29 10 NYCRR 711. 2(a)(1) 2012 NFPA 101: 19. 1. 6. 1. 8. 2. 1, 8. 2. 1. 2 2012 NFPA 220: 4. 1 | Plan of Correction: ApprovedNovember 8, 2022 I. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? A) There were no residents cited in this K tag. On 9/14/22 the facility received documentation from Tobin & Pams Design Architects that the original design meets or exceeds construction type 11(222) per NFPA [PHONE NUMBER], which per NFPA [PHONE NUMBER]- table 19. 1. 6. 1 is permitted for sprinkler building over 4+stories. This is represented in the original design drawings which indicate that the Schachne building is protected by a 2 hr. rated ceiling / floor assembly, which consists of a fire rated ceiling (in lieu of steel fireproofing). The facility maintains the documentation from the Architect who evaluated the ceiling design and determined that the Schachne building is in compliance with NFPA 101 . In regard to the facility had previously identified a total of approximately 946 separate improperly sealed plumbing and HVAC penetrations in floor and ceiling slabs. The plumbing penetrations come through the decking into a sheetrock wall above, and the HVAC piping come through the metal decking into the equipment above. The FSES and the Architect evaluation of the ceiling show that the facilities maintains a 2hr fire rated encloser and the plumbing and HVAC above the 2hr rated encloser are of no concern as per documentation on 11/4/2022 from Pinner Architects. B) All lighting fixtures located in the Schachne building have been inspected to ensure they are enclosed in a fire rated tent construction. Any quality issue which was identified have been addressed as of 10/27/2022 and are in compliance at this time. C) On 10 / 7/ 2022 The facility contracted with Pinner Architecture to complete an FSES. D) On 11/3/22 the facility received a completed FSES analysis from Pinner Architecture, PLCC. The conclusion of the FSES analysis show a level of safety that is at least equivalent to that prescribed in NFPA 101 in all safety categories. E) A copy of the completed FSES is maintained at the facility as proof the building meets the minimum standards for Design and that the original design meets or exceeds construction type 11 (222) per NFPA [PHONE NUMBER], which per NFPA [PHONE NUMBER]- table 19. 1. 6. 1 is permitted for sprinkler building over 4 +stories. This is represented in the original design drawings which indicate that the Schachne building is protected by a 2-hr. rated ceiling / floor assembly, which consists of a fire rated ceiling II How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents could be affected by this deficiency III. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? A) Chief Engineering Officer or designee will monitor all materials used for repairs of the existing ceiling. All materials will meet the specifications of original design or exceed the requirements of the required NFPA [PHONE NUMBER] B) All Engineering Staff have been in serviced on this policy and the K161 requirement by the Chief Engineering Officer/Designee. C) The Chief Engineering Officer/Designee has completed an in-service with all Engineering Staff on the proper lighting fixture tenting requirement if a light fixture needs to be moved for any reason. IV .How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? A) The Engineering staff will conduct an audit on all units annually due to the number of lighting fixtures and the extent of the inspection. 1 floor per quarter will be conducted to reach complete compliance yearly. B) All fixtures will be inspected to ensure they are enclosed in fire resistant rated construction. Any quality issue identified will have immediate corrective action taken. C) The results of audits will be presented to the QAPI committee for evaluation and review yearly. V. The date for correction and the title of the person responsible for correction of each deficiency Chief Engineering Officer |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2022
Corrected date: N/A
Citation Details 2012 NFPA 101: 9. 1. 3. 1 Emergency generators and standby power systems shall be installed, tested , and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2010 NFPA 110: 5. 6. 5. 6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. 5. 6. 5. 6. 1 The remote manual stop station shall be labeled. Based on record review during the Life Safety Code Post Survey Revisit on 10/25/2022 the facility did not provide substantial information to demonstrate that the Plan Of Corrections were implemented for one of two emergency generator sets in that there was no evicence for the installation of a remote stop station for generator # 1. The finding is: The facility was cited for the following during the 08/22/2022 recertification survey. During the Life Safety Code survey on 08/18/2022 at 11:35am, it was noted that Generator #1 was located within a room on the roof of the B- building and was not equipped a remote manual stop station located outside of the room. 2012NFPA 101 2010NFPA 110 10 NYCRR 415. 29 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedNovember 4, 2022 I. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? A) There were no residents cited in this K tag. B) On 10/28/2022 Generators # 1 new stop switch was completed. Gen Serve replaced controls and annunciator panel. Unit was tested and new stop switch shuts down unit as required. no further action is required. II.How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents could be affected by this deficiency. III. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? A) The Chief Engineering Officer reviewed the new stop switch is in place and operational B) All engineering staff have been in serviced on the generators new stop switch and proper operation by Chief Engineering Officer/Designee. C) The Chief Engineering Officer/Designee has in-serviced all engineering staff on the requirement for generators to have a remote manual stop station outside the room. IV. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Chief Engineering Officer will report during the QAPI meetings in (MONTH) and (MONTH) that the generator testing has been satisfied and the functioning status of the remote manual stop station for generator # 1 5. The date for correction and the title of the person responsible for correction of each Deficiency Chief Engineering Officer |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |